We’re Not Lost, We’re Exploring…

Well here we are again, albeit a little sooner than anticipated, with a new project! Our previous review topic (effectiveness of different social work models) has been put to one side pending the publication of more primary research and we’re already sinking our teeth into something new.

The “something new” is organisational interventions aiming to reduce the length of hospital stay (LoS) for older adults undergoing elective surgery.  The focus on “elective”, or planned, surgery arose due to interest in supporting hospitals to undertake a proactive approach to managing known factors which may increase the duration of a patient’s stay in hospital.

Our starting point was to identify and understand the factors which may increase LoS and available hospital-based interventions used to manage these. We spoke to a local consultant geriatrician, who helped us to think about the typical journey an older person through the hospital system. We also discussed how the responsibility for ensuring that this potentially vulnerable patient group has an appropriate length of stay does not just lie with the hospital itself.  These early conversations helped us focus our search for a relevant research question.

In At the Deep End…


Diving deep into the existing literature

The next step was to look in the published literature to help us understand the different factors which may influence an older person’s LoS. We had a splash course in getting up to speed with some of the existing organisational interventions used to reduce length of hospital stay, such as Enhanced Recovery After Surgery programmes (ERP/ERAS) and Comprehensive Geriatric Assessments (CGA). As none of the team hold medical degrees, getting to grips with the names of some medical procedures provided an interesting challenge!

Our preliminary scoping searches revealed that this is an area which has generated a lot of interest, including several existing systematic reviews (e.g. Bagnall et al (2014), Conroy et al (2011)). This is perhaps unsurprising given the increased demand experienced by many health services by an older population. If the literature base for social work was too sparse to justify conducting a systematic review, here we appeared to have the opposite problem; identifying a clinically useful question with an associated body of research, which has not already been reviewed. We did not want to conjure up a research question based upon an identified gap in the literature, which was academically interesting but of no use to clinicians/service managers on the ground. Likewise, we needed to make sure that some of the clinical issues we had identified had not already been subject to a systematic review.

A Guiding Light: The Role of Expert Advice


Stakeholders: a guiding light

Discussions continued with our clinical colleagues – we enlisted the help of a physiotherapist and occupational therapist in addition to our friendly consultant geriatrician. This provided us with some knowledge of the organisational systems in NHS hospitals which aim to ensure patients receive the care appropriate to their needs with minimal potential harms which in turn aided us in focusing our research question. We will be continuing these conversations and expanding them to include patients, other clinicians and service managers as the review progresses to ensure that it remains relevant to those it is intended to benefit.

Circling the Question Generation Cycle


Circling our Question

With lots of background knowledge and reading (e.g. Miani et al, 2014; Paton et al, 2014) under our belts we began the “Idea for a question – explore existing research – back to question” cycle. Each iteration through the cycle resulted in the team becoming more immersed in the research. This was a strange period of uncertainty and doubt. Often it felt as though we were taking two steps forward, followed by one-step back, as our preliminary scoping resulted in us returning to older ideas that had been proposed earlier in the process. Some of our early question ideas were as follows:

  1. A systematic review of qualitative research to identify and explore the influencing factors necessary for successful implementation of an ERAS/ERP intervention.
  2. A conceptual mapping review to better define/produce a typology of interventions aiming to reduce length of stay.
  3. A systematic review identifying key components of an ERP intervention for different patient populations (people with dementia etc.).

Spreadsheets and mind-mapping were useful tools to help anchor our thoughts and keep track of progress. Whilst initially frustrating and a little overwhelming, over time our familiarity with the existing literature grew and we were able to refine our ideas.

And Our Question Is….

hand with shell

Whilst all the above questions may represent important topics to address through systematic review, we kept returning to the broad concept of wanting to know whether existing organisational interventions were effective for older adults within a hospital setting. We decided that our focus should continue to be broader than elective surgery and also encompass other elective treatments, such as chemotherapy.

Hence, it was decided that our research questions should be:

  1. What is the effectiveness of hospital-based interventions to reduce length of inpatient stay in hospitals for older adults following planned admission?
  2. What is the cost-effectiveness of hospital-based interventions to reduce length of inpatient stay in hospitals for older adults following planned admission.

Just Keep Swimming

Of course that wasn’t the end of the story, discussions continued to further refine and define the components of the question – some of the things we’ve been grappling with are:

  • Who is an “older” patient? What does being “old” mean, exactly? Is it your number of years on this planet, or is it the change in your health and the support you need as you age? This question has been approached in many different ways….
  • What is an elective treatment? Do we include people who were admitted to an Intensive Care Unit after undergoing an elective treatment? It’s hardly a treatment pathway someone decides they’d like, but there is potential to develop a planned care package in advance.
  • What is an organisational intervention? What is the definition of an organisational intervention? We want to know what it is that is being done, how it is being implemented and who it carrying it out. Some of the studies exploring the effectiveness of certain types of intervention (e.g. CGA) don’t tell us much about what the intervention consists of or how it is carried out.
  • How can we usefully define “length of stay”? Is it just the number of days in hospital after the first admission or should we also be interested in readmission data? How is that defined clinically and in research studies?
  • How can we judge whether interventions intended to reduce length of stay? Should LOS be the primary intended outcome in our included studies?  Should we include only those that stated this as their aim, or also those that said they aimed to ‘improve recovery’ or ‘accelerate rehabilitation’?  Or should we include evaluations of all eligible hospital-based interventions where LOS is an outcome measure?

We have made decisions about most of these uncertainties, based on stakeholder input, pilot screening and discussion among the team, but still have some more thinking to do. Stay tuned whilst we dig into the nitty gritty of defining our inclusion and exclusion criteria and (hopefully!) turn this grain of sand into a pretty pearl.

Posted in Chris, Hospital, Jo, Length of Stay, Liz, methods, Michael, Older Adults, Question Generation, Rob, Simon, systematic review | 2 Comments

Social Work Practice in the UK: a ‘pre-scoping’ exercise

At the Exeter HS&DR Evidence Synthesis Centre, we have just come to the end of what could be described as a ‘pre-scoping’ exercise on the topic of the effectiveness of different models of social work practice in the UK. I call it ‘pre-scoping’ because we haven’t performed a systematic scoping review, but we were tasked with getting on board with the state of play, in anticipation of the outcome of a James Lind Alliance Priority Setting Partnership exercise, to be completed in 2018.

The core review team of Michael, Liz and Simon set about the process of learning what they could about social work in the UK, feeding back this information, and reporting to HS&DR with a broad overview and some suggested review questions. As a team we had almost no prior knowledge of social work, and started from scratch. This is often the case with systematic reviewers who may be ‘guns for hire’ as methods specialists, often coming together with topic experts to help make sense of it all. As this was a new topic area for us, starting in a new team, on our first project, we thought we would blog about our experiences.



We called this a ‘pre-scoping’ exercise

We will usually receive a ‘topic brief’ when beginning new projects. This sets out the rationale for research, some key publications to read and so on. On this occasion, we had only a broad question and a name. That name was Lyn Romeo – Chief Social Worker for Adults in England, at the Department of Health. After a period of digging for publications and relevant policy, we had the chance to speak with Lyn for some more direction, but prior to that it was a case of hitting the internet for some of the basics … like what is social work? For a start, and what on earth is a ‘model’ of social work practice?

At first, we wondered quite what we were getting ourselves into. Our initial database searches revealed very little primary evidence, while searching for ‘social work practice’ and the like on Google Scholar returned, rather alarmingly, a lot of books. Yes, there is an abundance of theory about how to do social work, but thus far the randomised controlled trials of said practice were eluding us.

We decided to ‘go grey’ and party with Scholar’s older, cooler sibling, Google. Inevitably, this revealed an array of web pages, blogs, commentaries and internet resources, which started to shed some light on the topic and, of particular value, some of the big issues. One really useful resource was Lyn Romeo’s blog (duh!). This was a great way to get up to speed with hot topics in social work. Not only this, but in her role she has published annual reports on the status and progress of social work in the UK. Akin to this was the British Association of Social Workers website, which is home to the largest professional association for social workers in the UK, and a rich resource for learning about the role.


Going to the grey literature was a particularly helpful starting point

Other key websites for anyone looking include www.scie.org.uk (Social Care Institute for Excellence), www.iriss.org.uk (The Institute for Research and Innovation in Social Services) and www.sscr.nihr.ac.uk  (the NIHR School for Social Care Research). We even found the odd research paper – for example a directly relevant review of adult social work by Jo Moriarty and Jill Manthorpe from King’s College published in 2016. It was clear from reading this review, and our own digging, that we weren’t about to tap into a body of high quality evidence for the effectiveness of social work practice – despite seeing calls for evidence from various bodies and individuals for the last 20 years.

While we weren’t uncovering tons of evidence, we were putting together a rogue’s gallery of stories about social work, with some quite startling details emerging. Here are some of the eye-openers:

  • Being a social worker is tough! Most people probably appreciate that on some level, but did you realise the average career length of a social worker in Britain is around seven to eight years, compared with 12 years for nurses and 25 years for doctors? The main reason for this seems to be the high-levels of burnout caused by a combination of stress, time-pressures and limited resources. A 2015 Research in Practice Strategic Briefing gives a lot of the gory details about workload, recruitment and retention – it’s not a pretty picture
  • Social workers have unique skill sets and often undertake roles that cross a variety of disciplines. The now defunct College of Social Work describes the varied role of social workers, which can require expertise in legal issues, social skills, delivering physical and mental health therapy and advice, and often making highly important and impactful decisions in pressurised situations. The crucial and delicate nature of the role and the guiding principles of social work practice are elegantly illustrated in this quote:

“Social workers play a pivotal and often leading role in safeguarding people’s rights, building relationships to support and empower children, adults and families to make important choices about the direction of their lives” (The College of Social Work, 2015, p3)

Social workers need skills that make them personable but assertive, empathetic but decisive, and able to work under great pressure. An ethnographic exploration of the ‘Front Door System’ highlights the sheer workload faced by social workers receiving a steady stream of referrals about which they must make the sort of decisions that could have severe consequences if incorrect.

  • Government policy around social work seems to be ever-evolving. The Care Act 2014 emphasises a shift towards a person-centred or strengths-based approach, although we couldn’t find research evidence about whether such an approach improves outcomes. Education and regulation of social workers is also in a state of flux. Social work is a protected profession, currently regulated by the HCPC (Health Care Professions Council), which regulates a range of other professional bodies in the UK. However in April, The Children and Social Work Act was given Royal Assent, and one of the key implications of this Act is that regulation of social worker education will be the responsibility of a new body called Social Work England as of September 2018.

This is another change in a landscape which has been in something of a hiatus since The College of Social Work– a body that aimed to raise professional standards and present a worker-led voice for reform – was deemed not financially viable and was closed down in 2015 after just four years. The HCPC worked with the College of Social Work between 2012 and 2015 to raise standards in social work education and improve the dual accreditation/endorsement process. Since its closure in 2015, the responsibility for social worker endorsement has fallen to educators and employers, with uncertainty about the next steps.

Through our relatively informal synthesis of a range of reports, commentaries, blogs and research articles, we were struck by how challenging the role of social worker can be and disappointed by reports that social workers can struggle to fulfil their vital role within a difficult culture, which at times may lack organisational clarity and support. There seems to be a need to streamline processes, provide evidence to support difficult decisions, and allow time for reflection on practice. In one of her blog posts, Lyn Romeo highlights the need for a culture shift within social care practice, from the risk-averse system which promotes defensive practice to one which encourages learning from mistakes and supported practice.


A strengths-based approach aims to work closely with the individual

As reviewers, we struggled to (and anticipate further struggle) get to grips with such a broad area, and in particular the challenge of defining and identifying models of practice, such as identifying when a ‘strengths-based approach’ is being used. The Moriarty and Manthorpe report highlights such challenges, and additional considerations such as the measurement of ‘effectiveness’ of social work, or that many evaluations of health and social care interventions poorly describe the professional background of individuals providing or coordinated the care. However, this is our field of expertise, and we’re keen to take on this challenge (and tell you about it).

While evidence synthesis is needed to help inform policy makers and social workers alike, our ‘pre-scoping’ exercise reaffirmed the need for more and better primary research to take place first, particularly in the UK. The next period of research prioritisation, through the James Lind Alliance, is an important step in the right direction in an area crying out for better evidence, and we will be poised and ready to fulfil our role when the time is right!


Posted in methods, Michael, social work, systematic review | 7 Comments

From new posts to blog posts – Welcome!

Welcome to the blog of the team of the book of the film based on the true-life adventures of the Exeter HS&DR Evidence Synthesis Centre!  We are Rob, Jo, Chris, Michael, Liz, Simon and Sue, and over the next three years we will be producing rapid, responsive and relevant systematic reviews of evidence about the organisation and delivery of health care and other services.  We are based in the ESMI research group at the University of Exeter Medical School.

The juicy bit in the middle …

We are really excited to be embarking on this programme of work.  This is partly to do with the variety and challenge of doing service-relevant work, but it’s also because we are passionate about what can be achieved through health services research. We are looking forward to synthesising evidence about the middle ground between individual treatments and the design and funding of the health system at the national level. This is the juicy bit!

2017-05-19 20.17.13

Such work involves identifying and making sense of the evidence looking at how different models of care or service commissioning can influence the lives of the patients. It could encompass subjects such as; evaluating different appointment systems, how person-centred care works, and what pathways of referral are best.

So why blog?

First and foremost, we hope that blogging will enable us to reach out to a wide range of stakeholders to whom our work will be relevant.  These stakeholders will be the potential users of our evidence synthesis findings, including health service managers, care professionals, commissioners and health care leaders and policy-makers.

But, we also want to engage with researchers and others who grapple with the inevitable challenges of producing useful insights and conclusions from diverse forms of evidence, on complex topics.

So the second aim of our blog will be as a kind of ‘reflective research diary’, for all of us in the team to capture and share what we learn through delivering this programme of work.  Rather than well-formed conclusions or clear suggestions for improvement, these ‘shared learnings’ will more often be recurrent ambiguities, intriguing differences, irrepressible excitements, practical frustrations, unexpected realisations, and undiscovered connections.  The kinds of thing that hardly warrant a full journal article but seem important and interesting enough to capture in passing.

At this point – being both new to the programme of work, and (for most of us) new to blogging – we don’t really know what we will actually blog about.  The range of likely topics is already hugely diverse and exciting (our first review topic, for example **watch this space** is not even within the realm of healthcare).  So some of our blog posts will inevitably share what we are learning about service or policy areas, or areas of management or implementation science, that are new to us.

We also have a strong shared interest in some methodological issues – for example, we want to explore the social process of systematic reviews.  Within team-based review processes, particularly of complex topics, much of the effort of synthesis and sense-making does not happen through a prescribed and linear processing of information.  Useful reviews of evidence about complex health service interventions require iterative cycles of data gathering, reading, reflection, dialogue, explanation-building/theorising, and numerous small judgements about the relevance and rigour of individual sources and pieces of evidence.  We believe these processes are an inevitable part of conducting high quality, useful evidence syntheses on complex topics – yet they are often poorly described (or even acknowledged) in most published systematic reviews.  Through our blog we hope to generate discussion on this and other methodological realities and fascinations that we face – and hopefully suggest and test some solutions that are useful to others too.

Please bookmark us.  Follow us on Twitter for notification of new blog posts: @ExEvidSC


Whose views? (disclaimer)

We should underline that the views and opinions in this blog are our own (specifically, the named member of the team who signs any post to the blog), and do not necessarily reflect those of the University of Exeter, the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.


Posted in evidence, methods, Rob, systematic review, team | Leave a comment